In medicine, as in other walks of life, there are many reasons why job performance may be impaired. These include substance abuse, neurologic disease, vision pathologies, common aging decline, psychiatric illness, emotional crises and orthopedic injuries. “Ten percent of all physicians will have some impairment over their career,” said George Bohigian, MD, who has presented on the topic at the Academy’s Annual Meeting. “Habitually excessive alcohol consumption accounts for 90 percent of that 10 percent.” Dr. Bohigian is professor of clinical ophthalmology at Washington University in St. Louis.

Aging and Injury

There are impairments with nonbehavioral origins, of course, such as skills dulled by simple aging or midlife disease. These do not need to spell the automatic end of a practice. A doctor diagnosed with Parkinson disease, for example, may exhibit tremors but still command excellent fine-motor control and full reaction times on medication. Individuals with serious orthopedic disorders may be fully rehabilitated, a process called remediation, said Dr. Bohigian. “Even individuals with only one functioning eye can practice surgery if they demonstrate performance skills up to community expectations and complication rates no higher than the average in his or her subspecialty.”

Substance Abuse

While the physician community’s access to extremely pure and potent drugs, such as fetanyl, has caused trouble, the most common problems by far are related to alcohol, said Dr. Bohigian. “When I was in residency, one of the first-year residents would constantly take breath mints and one day was discovered dead drunk in the nurses’ room. He came to me soon after for help and just started crying—he really was at bottom. But after recovering, he bounced back to a successful career, which included giving talks on alcohol abuse.” Indeed, 90 percent of alcohol-impaired physicians are reported to recover and return to a functional life, compared to a recovery rate of only 50 percent observed in the general population, said Dr. Bohigian.

What to watch for. Dr. Bohigian described some typical warning signs of substance abuse:

Poor performance, sloppy charting and failure to keep up to date with the professional literature

Missing appointments, being chronically late or behind, repeatedly changing surgery

Changes in attitude or behavior from, for example, receptive and attentive to abrupt and caustic; patients reporting that the physician exhibits anxiety or slurred speech.

Overcoming substance abuse. When physicians recognize their impairment and seek help before any authority or regulator becomes involved, they can enroll in self-help programs, said Mara Pearse Burke, manager of the Academy’s Ethics Program. “These programs include monitoring protocols, but their success depends upon the conscientiousness of both the recovering doctor and the mentor to whom monitoring has been delegated.”

Financial Repercussions

Evidence of substance abuse can be a key factor in court—even when a case begins as an unrelated malpractice lawsuit, said Anne M. Menke, RN, PhD, risk manager at Ophthalmic Mutual Insurance Company.

One example. She cited the example of an OMIC-insured ophthalmologist who performed routine bilateral LASIK, followed by bilateral re-treatment, on a patient who subsequently developed corneal ectasia severe enough to require corneal transplants. The patient filed a malpractice suit in which experts were critical of the decision to perform both the original surgery and the repeat procedures, given evidence of forme fruste keratoconus.

Substance abuse. In the middle of the investigation, a news article revealed that the physician had recently surrendered his license and entered rehabilitation for cocaine and alcohol abuse. The plaintiff quickly amended the suit to highlight the negligence of performing surgery while impaired, and asked for punitive damages, which aren’t covered by professional liability insurance. The new allegations prompted the defendant to enter settlement negotiations rather than go to trial, and doubtless increased the settlement value of the case.

How to Approach Your Colleague

Many impaired physicians are reluctant to report their difficulty to their colleagues, said Dr. Bohigian. “However, it is our ethical obligation to do that reporting for them, if a number of lesser remedies fail.” Dr. Bohigian described approaches to impairment in increasing order of gravity:

A friendly, one-to-one conversation. “First, upon observing events that suggest a colleague is impaired, try talking to him or her,” said Dr. Bohigian. “If the problem is alcohol, simply suggest they look at the CAGE Questionnaire,1 which is an easy list of questions that address typical evidence of abuse or functional impairments.” At this early stage, use a relaxed, nonjudgmental voice that assumes the situation can definitely be improved and you are there to help.

Document the physician’s failings. The evidence should be specific, not hearsay, said Dr. Bohigian, and ideally verified by other colleagues.

Bring colleagues into the conversation. “Immediately after documentation is initiated, and before a patient is seriously harmed, arrange to confront the colleague with a few other peers, for a firmer but still friendly intervention. Most hospitals have a ‘wellness’ committee of knowledgeable and sympathetic professionals, who will happily support this move,” he said.

Formal confrontation. If collegial confrontation does not evoke a response, Dr. Bohigian recommends talking to the chief of ophthalmology of the surgery center or a hospital executive to mount a more formal, institutional confrontation that carefully follows the institution’s bylaws. “The hallmark of impairment is denial and rationalization, on the part of ‘bystanders’ as much as by the impaired individual. Certain agents of authority may prove slow to act on this issue due to institutional denial,” he said, but their clout may be needed to impress the impaired party. In a smaller practice, it may be necessary to involve your colleagues in the physician community. “We’re not going to let you operate or practice medicine, and to achieve that we must report your situation to the licensing board” becomes the stark, next-to-last attempt.

Loss or suspension of license. If the above efforts go nowhere, the final, “best,” worst-case move is having the license of an impaired physician revoked or at least suspended before a patient is harmed. The “worst” of a bad situation, of course, is the loss of a patient’s organ, limb or life by an impaired physician who was not stopped.

If impaired physicians recover before any patients suffer serious harm, they may be able to win their license back. In fact, said Dr. Bohigian, physicians whose licenses were only suspended and not revoked can actually continue practicing if they agree to appropriate monitoring.

Picking up the pieces. “The challenge of rebuilding a practice depends on circumstances such as severity of the impairment, the depth of any denial, the prospects of retrieving an unencumbered license, the fallout of criminal charges, the publicity in the doctor’s community and that community’s capacity for forgiveness—and, of course, the supportiveness of family and friends,” said Ms. Pearse Burke.

Code of Ethics: Rule 5

According to the Academy’s Code of Ethics—which you can read in full at www.aao.org/ethics—a “physically, mentally or emotionally impaired ophthalmologist should withdraw from those aspects of practice affected by the impairment. If an impaired ophthalmologist does not cease inappropriate behavior, it is the duty of other ophthalmologists who know of the impairment to take action to attempt to assure correction of the situation. This may involve a wide range of remedial actions.”

Allegations of impairment. Physicians, patients and other parties can contact the Academy’s Ethics Committee to make a formal submission challenging the behavior of an Academy member. Although Rule 5 addresses physician impairment, “challenges that directly assert impairment have been very rare,” said Ms. Pearse Burke. “But some challenges have developed a component of impairment during the investigative process. These impairments have included:

Cognitive issues, such as poor judgment in treatment or in patient relations, reluctance to learn new techniques in the face of overwhelming evidence of improved safety and efficacy, unwarranted belief in a personal invention for treating eyes and a consistent failure to refer when appropriate;

Physical issues, such as tremors, weakness and visual problems; and

Drug addiction and behavioral problems, including those related to true psychiatric impairments as well as sexual harassment or abusive behaviors.”

1 The CAGE questionnaire asks whether you 1) have ever felt like you needed to Cut down your drinking, 2) get Annoyed by criticism of your drinking, 3) ever have bad or Guilty feelings about your drinking and 4) ever have had a breakfast-time drink (Eye-opener) to steady your nerves or get rid of a hangover. Ewing JA. JAMA. 1984:252(14).